NSE 203 Final Review Exam Questions With
Correct Answers
Clinical deterioration not promptly recognized can - answer✔increase pt morbidity & mortality
barrier to recognizing & responding to clinical deterioration stems from ... - answer✔practice
variations among HCP
consequences of not recognizing patient deterioration - answer✔increased mortality,
resuscitation, implementation of higher lvl of care & prolonged hospital admission
What is part of an ABCDE assessment? - answer✔1) airway
2) breathing
3) circulation
4) disability
5) environment & exposure
priority things to look for in pt airway? - answer✔- any blocked or threatened airways
- pt LOC
- abnormal respiratory assessment findings (ex; stridor)
if you suspect neurological trauma when assessing airway you ... - answer✔start w/ triple
airway maneuver!!
decompensation - answer✔inability to maintain homeostatic fxn physiologically or
psychologically
what are indicators of clinical deterioration - answer✔- sudden and/or unstable changes in vital
signs (RR, BP, HR, O2)
- for expert nurses, their intuition helps them determine if a patient looks right
- skin color changes
- decreased LOC
assessments to recognize deterioration - answer✔ABCDE
NEWS2
FAST
signs during primary survey that are *significantly associated w/ death* ... - answer✔- partial
airway obstruction
- poor peripheral circulation
- greater than expected drain fluid loss
- decreased UO
- decreased GCS
- abnormal RR
- new pain
- low O2sat & low BP
- alteration in mentation
NEWS2 aka - answer✔national early warning score
purpose of NEWS2 - answer✔- improve detection of & response to clinical deterioration in
patients w/ acute illness
- provide *standardized approach* to care of deteriorating patient
- clear communication
- identify a *score* for urgent clinical response
NEW score of 3, clinical risk & response - answer✔low-medium, urgent ward-based response
NEW score of 5-6, clinical risk & response - answer✔medium, key threshold for urgent response
NEW score of 7+, clinical risk & response - answer✔high risk, urgent or *emergency response*
what is FAST used for? - answer✔to identify most common signs of stroke (ischemic,
hemorrhagic or mini)
if a patient shows a FAST symptom ... - answer✔emergency action is required . Call 911
(outside), or stroke team (inside)
what does FAST stand for? - answer✔F(acial dropping)
A(rm weakness)
S(peech slurred/jumbled)
T(ime to call 911 or help right away)
interpersonal violence includes - answer✔- intimate partner violence
- sexual violence
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